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Patient Name _______________________________ Birthdate _______________ As the parent(s)/guardian(s) of _____________________________, I/we have discussed with the doctor the risks and benefits of the following initialed vaccines: POLIO: I/we have been informed of the risk of my
child(ren) developing paralytic disease and meningitis associated with
poliomyelitis.
HEMOPHILUS INFLUENZAE B: I/we have been informed
of the risk of my child(ren) developing meningitis, pneumonia, and infections
of the blood, joints, bone, and soft tissue associated with Hemophilus
influenza B.
STREPTOCOCCUS PNEUMONIAE: I/we have been informed
of the risk of my child(ren) developing meningitis, pneumonia, and infections
of the blood, joints and bone associated with Streptococcus pneumoniae.
PERTUSSIS: I/we have been informed of the risk of
my child(ren) developing whooping cough, pneumonia, convulsions, inflammation
of the brain, and death associated with pertussis.
DIPTHERIA: I/we have been informed of the risk of
my child(ren) developing paralysis, heart failure, or respiratory failure
associated with diptheria.
TETANUS (LOCKJAW): I/we have been informed of the
risk of my child(ren) developing fatal neuromuscular disease related to
tetanus.
RUBEOLA (MEASLES): I/we have been informed of the
risk of my child(ren) developing pneumonia, encephalitis (inflammation
of the brain), degenerative disease of the nervous system with convulsions
(subacute sclerosing panencephalitis) related to rubeola.
MUMPS: I/we have been informed of the risk of my
child(ren) developing inflammation of the testicles, joints, kidneys, and/or
thyroid, and hearing impairment related to mumps.
RUBELLA (GERMAN MEASLES): I/we have been informed
of the risk of my child(ren) developing inflammation of the brain or joints,
and of the risk of birth defects (including eye defects, heart defects,
deafness, mental retardation, growth failure, jaundice, and disorders of
blood clotting) in infants born to mothers who contract rubella during
pregnancy, related to rubella.
HEPATITIS B: I/we have been informed of the risk
of my child(ren) developing Hepatitis B viral infection which can cause
chronic inflammation of the liver leading to cirrhosis, liver cancer, and
possibly death.
VARICELLA (CHICKENPOX): I/we have been informed
of the risk of my child(ren) developing varicella viral infection which
could potentially result in pneumonia, encephalitis (inflammation of the
brain), secondary skin or generalized infections, or, if caught during
pregnancy, birth defects in the fetus.
I/we understand that by refusing the vaccines initialed above, I am acting against the recommendations of my child(ren)'s physician(s) and am placing my child(ren) at risk for developing the conditions described above. I/we understand that Dr. _______________ and/MDs4kids Medical PLLC or any of its employees or physicians are not legally liable for any claims or expenses that may arise should any of my child(ren) contract one or more of the above illnesses. By signing this statement, I/we acknowledge that I/we are aware that the above illnesses can safely be prevented by commonly administered immunizations and that I/we are, of our own free will and with full disclosure, acting against the recommendations of Dr. ________________ and/MDs4kids Medical PLLC and refusing the above initialed immunizations for our child(ren). I/we acknowledge that I/we have received written and verbal information about each of the conditions listed above and have had ample opportunity to have my/our questions answered by our child(ren)'s physician. Signature (mother)_______________________________Date____________ Signature (father)________________________________Date____________ Signature (guardian)______________________________Date____________ Signature (Physician/PA/NP)_______________________Date____________ Signature (Witness)______________________________Date____________
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--updated 18-Jul-00